Note: Click the link above to view the LIPA District Map in a seperate window in your web browser. Navigating away from this page without submitting will cause loss of form information.

LIPA Membership Application

 

Please complete the following fields. Upon submission of this online form, you will be emailed a hard copy of our member application that must be filled out, signed and returned to LIPA. We will contact as soon as your application is approved. Terms not otherwise defined herein shall have the meanings ascribed thereto in the Articles of Incorporation or the By Laws of the Corporation.

Section 1 - Name of Pharmacy on Permit from Louisiana State Board of Pharmacy (if applying as a Membership Group, list each Pharmacy to be included in the Membership Group)

 1
 2
 3
 4
 5
 6
 7
 8
 9
 10
 11

Section 2 - The following individual is hereby appointed as the Membership Representative to receive notices, vote and represent the Member in all Membership matters:

Section 3 - By signing this Agreement, the undersigned as the Authorized Signatory, does represent and warrant that he/she is a the duly authorized representative of the Member and does further covenant and agree that the Member shall follow all of the rules, regulations and requirements established by the Articles of Incorporation and By-Laws of the Corporation and that the Member does agree to pay the required Initiation Fee and monthly Assessed Amount as provided for from time to time in the By Laws of this Corporation.

reload